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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801300
Report Date: 10/25/2022
Date Signed: 12/19/2022 03:46:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20221019154835
FACILITY NAME:HOME SWEET HOME CAREFACILITY NUMBER:
565801300
ADMINISTRATOR:GLORIA P. VALENCIAFACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
07:34 PM
MET WITH:Rosie GonzalesTIME COMPLETED:
09:33 PM
ALLEGATION(S):
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Staff are not providing care and supervision to residents at night.
Staff do not assist resident with bathroom needs resulting in resident left soiled.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio and Teresa Camara conducted an initail complaint visit to the above facility. LPAs met with staff member Rosie Gonzales. Administrator Gloria Valencia was contacted by phone at 8:05 p.m. and authorized staff Gonzales to sign the documents. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 10/19/2022 regarding staff are not providing care and supervision to residents at night and staff do not assist resident with bathroom needs resulting in resident left soiled. During Resident #1 (R1) interview starting at 7:43 p.m., R1 stated that the staff do not really check on the residents at night. R1 added that they have a bell that they use to ring for help but it does take a bit of time for staff to respond, specially at night sometimes they dont come at all. Interview with R2 starting at 8:10 p.m. revealed that when in need of assistance, R2 uses the bell but no one arrives to help. R2 also adds that staff do not come in at night to check on them. R2 added that once they get laid in bed, no matter the time they are put to bed, the staff do not check in on them. R2 stated they wont see a staff member until the next morning.
Continued on lIC 9099 - C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20221019154835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
VISIT DATE: 10/25/2022
NARRATIVE
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Based on interviews, the allegation Staff are not providing care and supervision to residents at night is substantiated at this time.

Regarding the allegation of Staff do not assist resident with bathroom needs resulting in resident left soiled. Interview with R1, starting at 7:43 p.m, revealed that the staff do not really check on the residents at night. R1 added that they have a bell that they use to ring for help. R1 also mentioned that they hate to bother the night staff for any incontinence needs and will not call for help until their adult diapers are not comfortable. Interview with R2 starting at 8:10 p.m. revealed that when in need of assistance, R2 uses the bell but no one arrives to help. R2 also adds that staff do not come in at night to check on them. R2 added that once they get laid in bed, no matter the time they are put to bed, the staff do not check in on them. R2 is not strong enough to get out of bed independently. R2 stated they wont see a staff member until the next morning. R2 added because no one check on them at night, they are left soiled all night long until the next morning. R2 stated that staff have told R2 to urinate in their diapers and they will change them later. Based on interviews, the allegation of staff do not assist resident with bathroom needs resulting in resident left soiled is deemed substantiated at this time.

2 citations were issued during today's visit. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 9099-D):

Exit interview conducted, today's report and appeal rights were reviewed and emailed to Admin.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20221019154835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...
This requirement was not met as evidenced by:
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Admin will conduct training on all staff about regulation 87465(a)(2). Admin will provide training material and attendees of the training to CCL.
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Based on interviews, the licensee did not comply with the section cited above as R1 and R1 stated staff are not providing care and supervision at night to resident which poses an immidiate health, safety and personal rights risk to persons in care.
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Type A
10/26/2022
Section Cited
CCR
87468.1(a)(1)
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87468 Personal Rights of Residents in all Facilities (a)(1) Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons.
This requirement was not met as evidenced by:
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Admin will conduct training on 87468 (a)(1) to all staff. Admin will provide training materials and attendees of the training to CCL.
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Based on interviews, the licensee did not comply with the section cited above as R2 stated they have been left soiled all night which poses an immidiate health, safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20221019154835

FACILITY NAME:HOME SWEET HOME CAREFACILITY NUMBER:
565801300
ADMINISTRATOR:GLORIA P. VALENCIAFACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
07:34 PM
MET WITH:Rosie GonzalesTIME COMPLETED:
09:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not allow resident to drink at night.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio and Teresa Camara conducted an initail complaint visit to the above facility. LPAs met with staff member Rosie Gonzales. Administrator Gloria Valencia was contacted by phone at 8:05 p.m. and authorized staff Gonzales to sign the documents. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 10/19/2022 regarding staff not allowing resident to drink at night. During interview with three (3) resident starting at 7:43 p.m., LPA observed staff bring a glass of water to one resident, and observed various drinks on the other 2 resident. During the interviews, residents also stated they dont drink much water at night but will have a glass ready to go before bed. Residents also added, that they can reach a staff member if they want a drink but occasionally don't.

Based on observation and interviews the allegation, staff does not allow resident to drink at night is unsubtantiated at this time.
Exit interview conducted ad copy of the report provided to admin via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4